Less than 2 weeks ago, a close relative was hospitalized with acute promyelocytic leukemia and was immediately started on an aggressive treatment. Needless to say, her immune system is shot. To the family, the hospital room and area she's in are not as sterile as we want. The only precaution her guests are required to follow is to wash their hands and wear face masks if they have a cold. Although it is not required, the family have all opted always to wear masks to protect her while visiting. It is also apparently not required for the hospital staff to wear masks while interacting with her. Is this normal? Is it okay that we wear our street clothes and shoes while visiting? What determines how sterile of an environment an immunosuppressed patient should be in? The exact condition? The quality of the hospital? Can/should we demand more from the hospital? Should we seek treatment elsewhere? Am I over-reacting?

You are not the patient's doctor, but if you have any relevant advice or experience, please share.

My friend has leukemia and I've sat in with him during chemo (through IV) and have never been required to change/wear a mask. I wasn't there during the early stages, but I asked a similar question to another friend who was visiting him then, and he said that as long as you didn't have a cold, it was all good.

This was at a nice Canadian hospital.posted by 913 at 12:56 PM on January 28, 2008

Well, I have current and painful first hand experience to share, seeing as you asked. My father is currently in intesive care (and not expected to last the next 24 hours) having contracted pneumonia as a result of his immune system being shot through chemo for Hodgkins (the brutal tragedy is that he was hostpitalized with pneumonia on the day he went for his final precautionary chemo, the Hodgkins having been cured). So his experience shows how deadly infection is when your immune system is shot and that you are right to be cautious.
The hospital are very infection aware: you are made to disinfect your hands with alcohol gel on entering and leaving any wards, and there is alcohol gel at the end of the bed which we use whenever we've touched anything (e.g. a chair). You have to wear a disposable plastic apron at the side of the bed, which you have to dispose of when you leave the side of the bed. You are not allowed to visit if you or a member of your family has had sickness or diarrhea in the last 24 hours. Other than that, we wear our street clothes and shoes, and don't wear masks.
So, if they don't supply alcohol gel, I'd suggest buying a bottle yourself.
I hope that helps.posted by chill at 12:58 PM on January 28, 2008

Sorry, I meant to say "sickness or diarrhea in the last 48 hours".posted by chill at 1:00 PM on January 28, 2008

I'm an RN. I've taken care of many immunosuppressed people. I don't anymore. I work with recovering cardiac patients that are well. I'll try to remember everything.

Handwashing and wearing a mask is standard procedure with people that are immunocompromised or neutropenic. A gown is too. There should be a supply of disposable gowns at the door. If I were this person's nurse I would wear a mask and gown every time. Gloves and a mask for sure. I don't know about booties. I've never worked on oncology. I hope somebody can answer this for you. Wearing disposable booties over the shoes cannot hurt. The nurses and doctors that are taking care of your relative are probably not wearing a mask because they are not ill or they don't remember? There should be an isolation precautions sign on the door. The door should remained closed.

It goes without saying, but your relative should have a private room.

Family members should never use the patient's toilet, obviously.

There should be a stethoscope, thermometer, and blood pressure cuff (and other supplies such as tape and scissors) kept in the patient's room. The nurses should also probably not be using scissors or tape out of their pockets to use on this patient if they have been used on other patients. She needs her own supply of everything. The nurses and aides should not enter with vital sign equipment that is has been used on other patients. If the nurse or doctor uses their personal stethoscope it should be wiped down with an alcohol prep. The hospital should also have a separate supply of cleaning supplies that are kept in her room.

Don't bring in flowers or plants.

Don't bring too many home-cooked meals from home. They could be contaminated.

Your relative should receive a disposable tray and plastic silverware if she her immune system is suppressed. Is your relative on a neutropenic diet? The oncologist will order this if she deems it necessary.

If these things aren't being done, explain your concerns to the nurse manager or the nurse in charge. Ask some questions. They should answer all of your concerns.

Your family member should wear a mask when she leaves her room for Xrays, tests, etc.

As a nurse I would definitely wear disposable booties if my shoes were contaminated and my patient's immune system was severely compromised. Nurses shoes are disgusting as you can imagine. As far as visitors go it's probably not necessary, but I am not a doctor.

Health care professionals should always follow isolation procedures depending on the patient. We should also not add extra layers of protection unless necessary. Just as we wouldn't enter a person's room that was HIV-positive donned with a face shield (unless they had a sucking chest wound) and protective garb. We respect each patient and follow the standards of care for the type of isolation they require See here.posted by LoriFLA at 1:28 PM on January 28, 2008

There are degrees of immunosuppression, which require different levels of protection. You should discuss your concerns with the doc and nurses -- don't be afraid to ask questions.posted by desuetude at 3:07 PM on January 28, 2008

I've had the same impression with most hospitals I've been in. Sterile? Forget about it unless you're in an operating room. Basic sanitation is sometimes hard to find. I mean, MRSA started in hospitals.

Talk to that relative's physician along with the head of nursing, either for that unit or for the entire hospital. If you don't get an answer that satisfies you, keep going up.posted by gjc at 4:54 PM on January 28, 2008

Everything thus far sounds good, but here's one more suggestion:

Tell your family member that they have the RIGHT to ask everyone who walks into the room to wash their hands right then and there. I have researched this, and the hand washing compliance is absolutely abysmal. The hospital that I currently work at suggests that patients take this active role to ensure compliance with hand washing rules. Sometimes the people caring for the patient forget, or are "too busy" to remember to wash their hands. Remind them (and me) any time you want. If someone takes offense, don't sweat it. Hand washing is the one most necessary thing to help keep a clean room clean.posted by nursegracer at 5:03 PM on January 28, 2008

This sounds pretty standard to me. There's no clear consensus on the appropriate isolation measures in this circumstance, but what you describe is more or less what is done at the tertiary academic hospital where I work and take care of leukemia patients regularly. While your concern is much appreciated, most of the infectious risk in this scenario (look up neutropenia) is from the patient's own flora on the skin, airways and gut. The latter is the most common source of infection as chemotherapy itself breaks down the protective lining of the intestines causing bacteria already in the gut to translocate into the patient's bloodstream. Whether or not you wear a Hazmat suit into the room won't really change that, so good general practice is to stick to washing hands frequently and avoid close contact entirely if you or any other relatives feel remotely ill.posted by drpynchon at 6:27 PM on January 28, 2008 [1 favorite]

Thank you all; every single one of your comments is insightful.posted by ellenaim at 5:52 PM on January 29, 2008

I agree with drpynchon and desuetude.

I'm an oncology RN. I work with leukemia patients often. What you're experiencing is fairly standard. The level of precautions depends on their labs a lot. If their absolute neutrophil count (ANC) is less than 1000 then they are at a greater risk of infection. Neutrophils are the white blood cells that are largely responsible for fighting general infections. For my hospital this is the definition of neutropenia. This is when our staff begins to wear masks in the patients' rooms. Neutrophils are the white blood cells that are largely responsible for fighting general infections. Some places neutropenia is defined as under 2000, but our patients are always generally lower than that anyway.

drpynchon is right on about the patients' own flora putting them at risk. Generally right after chemo patients are given antibiotics, anti-virals, and antifungals as a preventitive measure.

Best wishes to you and your family. The support your family is giving your relative is invaluable. Talk with the staff so you can trust that they want to help all of you. That's why they are there. They want your relative to get better. Ask them questions.posted by dog food sugar at 6:54 PM on January 29, 2008 [1 favorite]

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